About the person who had the accident
Occupation (if they were at work, or their status (e.g bystander) if not at work
About you, the person filling in this book
Click here to sign
About the accident (when it happened. Where it happened)
Date and time
In what room or place did the accident happen?
About the accident - what happened (say how the accident happened. Give the cause if you can. If any personal injury say what it is)
How did the accident happen?
What treatment has been given?
Employers statement (Record comments here. If the accident is reportable under RIDDOR, record the date and method used when first advising the relevant authority. Initial the box provided)
Reporting of Injuries, Diseases and Dangerous Occurrences, RIDDOR 2013
Employers name and initials
Continue if required
Source: Blackhorse Workshop (Community Member)